Symptom Checklist
Personal Information
First Name
*
Last Name
*
Email
*
Phone
*
Date of Birth
*
Gender
*
Female
Male
Health Overview
Do you lack motivation, energy and feel burned out?
None
Mild
Moderarte
Severe
Extremely Severe
Do you experience frequent mood swings?
None
Mild
Moderate
Severe
Extremely Severe
Do you experience brain fog and/or insomnia?
None
Mild
Moderate
Severe
Extremely Severe
Do you feel anxious or depressed?
None
Mild
Moderate
Severe
Extremely Severe
Are you struggling with weight gain/belly fat?
None
Mild
Moderate
Severe
Extremely Severe
Are you struggling with joint pain or muscle ache? (lower back pain, joint pain, pain in limb,, general back ache?
None
Mild
Moderate
Severe
Extremely Severe
Do you have lower sexual desire/libido?
None
Mild
Moderate
Severe
Extremely Severe
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